ADA’s guide to substance abuse: An important resource

“I brush and floss everyday.” The little white lie heard around the world. It’s hard enough to surface our patients’ oral hygiene habits, and once we do, that only provides a limited scope of their at-home behaviors. When we review social histories, patients quickly deny the use of alcohol, smoking and recreational drugs. But can we take that to be true? If our patients cannot honestly discuss their hygiene regimen, imagine how much harder we have to press for accurate, personal details in regard to substance abuse and addiction. However, as health care professionals, we have a responsibility to treat total health. “The ADA Practical Guide to Substance Use Disorders and Safe Prescribing” presents ways to navigate these difficult patient interactions and even recognize those in similar situations among our dental community.

The review book opens with a simple overview of substance use disorders (SUDs). These include those associated with prescription medications, illicit substances and most commonly, alcohol. According to Michael O’Neil, Pharm.D., in a process called drug diversion, you, your colleagues or your patients can slip into a damaging spiral of selling or buying illegal substances. Recognizing abnormal behaviors of those with SUDs can help in early intervention and treatment. Staff and family should flag providers who withdraw from social and occupational activities, develop tolerance and crave substances. Patients who prompt family members to request medications, visit the office often and for no real reason, and report allergies to less potent opioids and nonsteroidal anti-inflammatory drugs exclusively should be closely monitored for SUDs. As you develop deeper relations with your patients and colleagues, be aware of any personality or behavioral changes.

To understand the exact pathophysiology of certain SUDs, the ADA Practical Guide delves into the biochemistry of different neurological pathways. Without getting overly technical, in a non-abusive state, the emotional center or prefrontal cortex (PFC) is chemically balanced with the reward center or nucleus accumbens. However, with growing addictive and abuse behaviors, the system is altered and the PFC is unrestrained. To better identify these manifestations clinically, James Berry, D.O. and Carl Rollynn Sullivan, M.D. provide sidebar commentary and tables for a wide range of substances. They include alcohol, benzodiazepines, opioids, stimulants, cannabis, nicotine, hallucinogens, designer drugs and inhalants.

Before considering more potent medications for pain management, Paul Moore, DMD, and Elliot Hersh, DMD, encourage the use of milder analgesics. Nonopioid analgesics, like acetaminophen and ibuprofen, have their share of adverse effects, but are commonly employed in surgical cases, like third molar extractions. However, as with any drug, the ADA Practical Guide warns of their contraindications, adverse reactions and polypharmacy, when used with other analgesics for acute and chronic pain conditions.

According to Dr. O’Neil, pain is largely influenced by the patient’s perception of pain and the dentist’s expectation of their pain. When using deeper levels of sedation and anxiolysis for pain relief and control, the chief goal is to minimize risk, while maximizing comfort and safety. Matthew Cooke, DDS, explains the different levels of sedation and their necessity for dental and surgical procedures in both children and adults. He reviews the use of sedative techniques before, during and after treatment and in emergencies. As generalists expand their repertoire to include these more advanced services, the ADA Practical Guide ensures their proper legal and medical execution.

But most notably, an entire chapter of this review book has been dedicated to the various forms, delivery models and management of tobacco use. Despite the advances in tobacco cessation, smoking remains the leading preventable cause of death nationwide. It is therefore our obligation to remove this destructive, behavioral etiology, as it pertains to their oral and systemic health. Dental interventions are only as good as they are maintained.

How do you begin these sometimes difficult conversations, though? The ADA Practical Guide suggests the following monologue: “I have a couple questions I need to ask to make sure there are not any life-threatening drug interactions with your dental treatment. Regardless of your answers, my intent is not to judge you, deny you treatment, or to notify law enforcement.” Motivational interviewing and effective listening can help build trust and loyalty in your doctor-patient relationships. You are not blaming or demeaning them for their behaviors, but instead opening meaningful dialogue. In cases where a colleague is victim to SUDs or addiction, family and staff both play an integral role in their intervention. Be wary of marital, social, physical or financial stressors.

Hopefully, you will not have to use this book often, but when you do, know that it can accurately access most SUD situations. You have the unique potential to provide total wellness for your patient. Don’t let a difficult conversation prevent you from providing the most comprehensive and quality-centered care.

~Adam Saltz, Nova Southeastern ’17, contributing editor

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Adam Saltz is the national editor-in-chief for ASDA. Originally from Maine, Adam is a fourth-year dental student at Nova Southeastern University (NSU). He obtained his Master of Public Health degree in 2016, while in dental school. He also serves as director of NSU’s Give Kids A Smile program. His efforts to improve access to quality oral healthcare earned him the 2014 ADA Foundation Bud Tarrson Dental School Student Community Leadership Award. He will be attending the University of Texas Health Science Center at San Antonio for their Advanced Education Program in Periodontics starting in June of 2017. When he's not keeping up with Bruins hockey, you can find him on the tennis court.